Eating Behaviors 21 (2016) 11–17

Contents lists available at ScienceDirect

Eating Behaviors

On orthorexia nervosa: A review of the literature and proposed

diagnostic criteria
Thomas M. Dunn a,⁎, Steven Bratman b
a
Campus Box 94, University of Northern Colorado, Greeley, CO 80639, United States
b
California Pacific Medical Center, 3700 California Street, San Francisco, CA 94118, United States

a r t i c l e i n f o a b s t r a c t

Article history: There has been a growing interest among clinicians and researchers about a condition where people restrict their
Received 27 July 2015 diet based not on quantity of food they consume, but based on its quality. Bratman (1997) coined the term
Received in revised form 13 November 2015 “orthorexia nervosa” to describe people whose extreme diets – intended for health reasons – are in fact leading
Accepted 16 December 2015
to malnutrition and/or impairment of daily functioning. There has also recently been intense media interest in
Available online 18 December 2015
people whose highly restrictive “healthy” diet leads to disordered eating. Despite this condition being first
Keywords:
described in the U.S., and receiving recent media interest here, orthorexia has largely gone unnoticed in the
Orthorexia nervosa North American literature. This review article details the literature of orthorexia nervosa, describing its
Eating disorders emergence as a condition first described by a physician in a yoga magazine, to its being discussed in the scientific
Unhealthy eating literature. It also reviews prevalence studies and discusses marked shortcomings in the literature. Finally,
diagnostic criteria are proposed, as are future directions for research.
© 2015 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2. Review of the literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.1. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3. Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.4. Existing criteria for ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.5. Measurement of ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5.1. ORTO-15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5.2. Measures based on the ORTO-15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5.3. Other measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.6. Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4. Proposed diagnostic criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4.1. Proposed diagnostic criteria for ON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.1.1. Criterion A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.1.2. Criterion B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
5. Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1. Introduction

⁎ Corresponding author.
Concerns about individuals who engage in pathologically healthful
E-mail addresses: Thomas.dunn@unco.edu (T.M. Dunn), stevenbratman@gmail.com eating have been of interest in recent years, primarily to European
(S. Bratman). researchers and clinicians. While a review (Vandereycken, 2011) of

http://dx.doi.org/10.1016/j.eatbeh.2015.12.006
1471-0153/© 2015 Elsevier Ltd. All rights reserved.
12 T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
Dutch speaking eating disorder specialists (n = 111) reports that most
are aware of the condition “orthorexia nervosa” (ON), peer-reviewed
scholarship regarding this topic has largely been absent in the U.S. liter-
ature, with only a single article on the topic appearing in a refereed,
North American journal (Moroze, Dunn, Holland, Yager, & Weintraub,
2015). The public's awareness of this condition began changing in the
summer of 2014. This is when a young woman in New York named
Jordan Younger, author of a highly successful blog called “The Blonde
Vegan,” surprised her 70,000 Instagram followers by admitting that
she suffered from an eating disorder that was not based on the quantity
of her food intake, but its quality (Pfeffer, 2014). Younger reported that
her drive for healthy eating had become pathological and resulted in
malnutrition. Major media outlets reported her plight and she was
interviewed on programs like ABC News' Good Morning America and
Nightline programs (J. Younger, personal communication, April 9,
2015) inspiring a flurry of other media coverage, such as articles in the
Wall Street Journal and Popular Science (Reddy, 2014; Schwartz, 2015).
It is remarkable that this kind of media coverage has been generated
for a condition not recognized by the Diagnostic and Statistical Manual
of the American Psychiatric Association (DSM-5) and not well
understood. The purpose of this paper is to review the literature of ON
and discuss diagnostic criteria.
2. Review of the literature
2.1. Method
The key words “orthorexia,” “orthorexia nervosa,” “pathologically
healthy eating” and “disordered healthy eating” were searched in
the databases Academic Search, Biological Abstracts, Google
Scholar, MEDLINE/PubMed, and PsychINFO. From these results, articles
appearing in peer-reviewed journals, books, and book chapters were
reviewed. Except for Bratman's (1997) original article, we excluded ar-
ticles that were commentary only, review articles that merely discuss
the literature, and items that were unavailable using interlibrary loan/
document delivery request through an academic library. Works that
were published in a language other than English (n = 3) were translat-
ed via Google Translate.1
2.2. Background
ON was first described by physician Steven Bratman in 1997, in an
article in Yoga Journal. To describe what he saw as a pathological
obsession with healthful eating, he coined the term “orthorexia
nervosa,” from the Greek “ortho” meaning “straight or “correct,” and
“orexi,” meaning appetite. He would later more fully detail the condi-
tion in a book (Bratman & Knight, 2000). Other than a review of this
book in JAMA (Fugh-Berman, 2001) that encourages the term
orthorexia nervosa entering the “medical lexicon,” the first article
appearing in a peer-reviewed journal was a 2004 Italian study that
described ON as a “maniacal obsession” in the pursuit of healthy foods
(Donini, Marsili, Graziani, Imbriale, & Cannella, 2004). This seminal
paper would give credibility to the condition and the term used to de-
scribe it, marking the transition of ON from informal musing into a con-
cept worthy of scientific exploration.
2.3. Case studies
Case studies have long been the mechanism to permit potentially
new medical conditions to be introduced into the scientific literature
(Vandenbroucke, 1999). Case studies often help drive early attempts at
evidence-based treatment and other best practices (Cabán-Martinez &
1
Balk, Chung, Chen, Trikalinos, and Kong (2013) report Google Translate as an accept-
able method of translation for data extraction, particularly when descriptive statistics are
being used.
García-Beltrán, 2012; Edwards, Dattilio, & Bromley, 2004). Soon after
the Donini et al. (2004) article appeared, case studies detailing individ-
uals thought to have ON started circulating in the literature. The cases
below are important as each describes pathological eating driven by a
desire not for thinness, but to have a diet perceived to promote good
health. In each case, the authors argue that the patient they describe
suffers from ON.
Zamora, Bonaechea, Sánchez, and Rial (2005) thoughtfully describe
the case of a 28-year-old woman with severe malnutrition, marked
hypoproteinemia, and vitamin B12 deficit, with a Body Mass Index
(BMI) of 10.7. At age 14 she was reportedly told by a nutritionist to
eliminate fats from her diet to help control severe acne that was refrac-
tory to traditional treatments. At age 16, she progressively restricted the
types of food she ate to an extreme “lacto-ovo-vegetarian” diet. By age
24, she had eliminated eggs and milk products. By the time of her pre-
sentation to the Zamora group, the patient's weight dropped to 27 kg
after isolating herself from friends and family and eating only uncooked
vegetables. Zamora et al. (2005) report that the patient had no typical
anorexia behaviors: she did not report a desire to be thin, nor did she
have distorted body image. She simply believed that different types of
proteins or nutrients in the same meal produced toxins and were to
be avoided.
Park et al. (2011) recount the case of a 30-year-old male who, in a
sole effort to treat a tic disorder, restricted his diet to only 3–4 spoons
of brown rice and fresh, unsalted vegetables. After three months, he
became “bedridden.” His extreme dietary restriction resulted in severe
medical consequences, resulting in a 38-day hospital stay to treat
metabolic acidosis, subcutaneous emphysema, pneumothorax and
pancytopenia. They do not report that he had self-perceived body
image disturbance, nor concerns of being overweight.
Saddichha, Babu, and Chandra (2012) report a 33-year-old woman
with an eight year history of maintaining an exclusive diet of only
fresh fruits, raw vegetables, and uncooked eggs. The patient did not
report concerns about her body type or weight, but reportedly became
obsessed about healthful eating. She reportedly was worried that
cooking foods would ruin their nutritional qualities. During this time,
she reportedly cut ties with her friends and family and developed a
BMI of 14.5 requiring medical intervention. Saddichha et al. (2012)
conceptualize this case as ON being a prodrome to developing schizo-
phrenia. They note that the patient had ON symptoms for seven years
before showing signs of a first time psychotic break. Her psychosis
reportedly had nothing to do with food, but concerned paranoid and
bizarre ideas about her family. These authors note other cases of eating
disorders preceding schizophrenia and argue that the ON was a distinct
process not better accounted for by psychotic illness.
Finally, Moroze et al. (2015) discuss a 28-year-old male with three
years of reduced nutritional intake, limited to self-made “protein
shakes” that included only pure amino powders. He stated that he
avoided commercial shakes, as they had unnecessary fillers. This restric-
tion resulted in severe malnutrition, he presented with a BMI of 12.3,
weighing 43.5 kg (50% of his ideal body weight). While this patient
initially started restricting his diet in response to an episode of constipa-
tion, over the period of years, his beliefs reportedly turned to eating food
based on its purity. At the time of his treatment, Moroze et al. (2015)
note that the patient said that his body was a “temple” and his diet
was designed to give him the “pure building blocks” that he needed to
be healthy. The authors include a lengthy discussion regarding differen-
tial diagnosis. Noting that the patient had no body image concerns or
issues regarding his weight, he was diagnosed with eating disorder
not otherwise specified (as DSM-IV was in effect at the time of their
evaluation).
2.4. Existing criteria for ON
As conceptualized by Donini et al. (2004), in ON, purity of food is
valued above all else, including deleterious health effects from such a
 T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
diet. They suggest those with ON feel anguish when not eating health-
fully, obsessiveness with planning and preparing healthy meals, and a
sense of superiority over others regarding diet (Donini et al., 2004).
From a sample of 404 Italians from the general population, Donini
et al. (2004) identified individuals believed to have “health fanatic” eat-
ing habits, as well as obsessive–compulsive traits and phobia as
measured by an elevated score on Scale 7 of the first edition of the
Minnesota Multiphasic Personality Inventory. These individuals (n =
28) were identified as having ON. Donini's group do not delineate
particular criteria that they believe to be unique to ON. Although Jessica
Setnick suggested sample criteria for ON in a self-published work in
2013, the first diagnostic criteria to appear in the refereed literature
accompanied the Moroze et al. (2015) case study (see Table 1).
2.5. Measurement of ON
In his book, Bratman and his co-author (Bratman & Knight, 2000)
describe a 10 item questionnaire in a yes/no format to identify those
at risk for ON. This scale is without basic psychometric properties,
such as data regarding validity, reliability, cut scores, or a reference
group. It was designed as a screening instrument, with items such as:
“Do you spend more than three hours a day thinking about healthy
food?” “Do you sacrifice experiences you once enjoyed to eat the food
you believe is right?” and “Do you keep getting stricter with yourself?”
Bratman has never suggested that these items are scientifically rigorous
and created it only as an informal measure. There are no interpretation
guidelines. These 10 items, however, are the basis of the “ORTO-15,” an
instrument designed to detect ON (Donini, Marsili, Graziani, Imbriale, &
Cannella, 2005).
Table 1
Moroze et al. (2015) criteria for orthorexia nervosa.
Diagnostic criteria
Criterion A. Obsessional preoccupation with eating “healthy foods,” focusing on
concerns regarding the quality and composition of meals. (Two or more of the
following.)
1. Consuming a nutritionally unbalanced diet due to preoccupying beliefs about
food “purity.”
2. Preoccupation and worries about eating impure or unhealthy foods, and on
the impact of food quality and composition on physical and/or emotional health.
3. Rigid avoidance of foods believed by the patient to be “unhealthy,” which may
include foods containing any fat, preservatives, food-additives, animal products,
or other ingredients considered by the subject to be unhealthy.
4. For individuals who are not food professionals, excessive amounts of time
(e.g. three or more hours per day) spent reading about, acquiring and/or
preparing specific types of foods based on their perceived quality and
composition.
5. Guilty feelings and worries after transgressions in which “unhealthy” or
“impure” foods are consumed.
6. Intolerance of others' food beliefs.
7. Spending excessive amounts of money relative to one's income on foods
because of their perceived quality and composition.
Criterion B. The obsessional preoccupation becomes impairing by either of the
following:
1. Impairment of physical health due to nutritional imbalances, e.g. developing
malnutrition due to unbalanced diet.
2. Severe distress or impairment of, social, academic or vocational functioning
due to obsessional thoughts and behaviors focusing on patient's beliefs about
“healthy” eating.
Criterion C. The disturbance is not merely an exacerbation of the symptoms of
another disorder, such as obsessive compulsive disorder, or of schizophrenia or
another psychotic disorder.
Criterion D. The behavior is not better accounted for by the exclusive observation
of organized orthodox religious food observance, or when concerns with
specialized food requirements are in relation to professionally diagnosed food
allergies or medical conditions requiring a specific diet.
Note: Reprinted with permission from Psychosomatics, Moroze et al. (2015)
Microthinking about micronutrients: a case of transition from obsessions about healthy
eating to near-fatal “orthorexia nervosa” and proposed diagnostic criteria, 56(4), 397–407.
13
2.5.1. ORTO-15
The ORTO-15 is a 15 item multiple choice questionnaire that
purports to identify ON in an Italian sample (Donini et al., 2005). In
creating the ORTO-15, Donini et al. (2005) use six of the 10 original
yes/no Bratman items and also generated an additional nine items.
Such additional items include “Are your eating choices conditioned by
your worry about your health status?”, “Are you willing to spend
money to have healthier food?”, and “Do you think that the conviction
to eat healthy food increases self-esteem?” Discarding the yes/no
format, Donini et al. believed that a “Latin sample” was “socially more
dialectic” than an Anglo-Saxon one, so expanded the scoring to a 1 to
4 scale (always, often, sometimes, never) regarding food preferences
and dietary habits (Donini et al., 2005). Higher scores indicate less
extreme dieting practices. A cutoff score of 40 was set as being able to
correctly identify the 28 individuals believed to have ON based on
their MMPI score and eating habits. A validation sample of 110
individuals also took the ORTO-15 and the authors found 100% sensitiv-
ity in identifying individuals with ON, 73.6% specificity, a positive
predictive value of 17.6%, and a negative predictive value of 100%.
The Italian items were translated into English for publication (Donini
et al., 2005).
2.5.2. Measures based on the ORTO-15
Since its publication, the ORTO-15 has spawned additional
versions that have been used in other languages. Versions where
the original ORTO-15 items and scoring are unchanged and simply
translated without modification include those in Turkish (Asil &
Sürücüoğlu, 2015; Bosi, Çamur, & Güler, 2007), Portuguese (Alvarenga
et al., 2012; Pontes, Montagner, & Montagner, 2014), Polish (Gubiec,
Stetkiewicz-Lewandowicz, Rasmus, & Sobów, 2015; Stochel et al.,
2015), and Spanish (Jerez, Lagos, Valdés-Badilla, Pacheco, & Pérez,
2015). The ORTO-15 has also been the basis for more complicated
adaptations for other languages as well. Table 2 lists various translations
into other languages, as well as modifications of the instrument
believed to be better suited for the language of the sample being
assessed. All four of these measures, the ORTO-11, the ORTO-11-Hu,
the Polish ORTHO-15, and the ORTO-9-GE, discard various items from
the original ORTO-15 based on confirmatory factor analysis and
goodness of fit. Across these four measures, however, all original
ORTO-15 items survive to be included in at least one instrument.
Indeed, both the ORTO-11 and ORTO-11-Hu contain four fewer
items than the ORTO-15; each instrument deleting four different
questions.
2.5.3. Other measures
While the ORTO-15 dominates the literature, several studies simply
use the original 10 item yes/no test Bratman described in his book
(Bratman & Knight, 2000). One of the earliest studies to examine
prevalence was Kinzl, Hauer, Traweger, and Kiefer (2005) assessing
286 nutritionists on what they describe as the “Bratman Test.” Similarly,
Korinth, Schiess, and Westenhoefer (2010) use the same scale, referring
to it only as the “ten items.” Neither study describes in detail the method
used to translate the English items into German. Eriksson, Baigi,
Marklund, and Lindgren (2008) coin these 10 items the “Bratman
Orthorexia Test,” and administer it in Swedish after a single step trans-
lation. For this review, these 10 yes/no items will be referenced as the
“Bratman Test.”
2.6. Prevalence
The limited literature regarding ON is dominated by studies
reporting point prevalence using the ORTO-15 or one of its adaptations.
Table 3 summarizes these studies, their prevalence rate, and their
country of origin. Generally, these studies are community or university
samples. The prevalence of ON varies widely from 6% in an Italian
sample to 88.7% in a sample comprised entirely of female nutritionists
14 T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
Table 2
Instruments assessing orthorexia nervosa (ON) based on the ORTO-15.
Study Name of new ORTO-15 items
measure discarded in new
measure
Arusoğlu, Kabakci, Köksal, ORTO-11 1, 2, 9, 15
and Merdol (2008)
Varga, Thege, Dukay-Szabó, Túry, ORTO-11-Hu 5, 6, 8, 14
and van Furth (2014)
Brytek-Matera, Krupa, Poggiogalle, Polish ORTHO-15 1, 2, 8, 9, 13, 15
and Donini (2014)
Missbach et al. (2015) ORTO-9-GE 1, 2, 8, 9, 13, 14
in Brazil. Most prevalence studies for ON regularly report rates from 30%
to 70%. On the surface, these numbers look alarming. However, these
findings are inconsistent with the broader understanding of eating dis-
orders that are believed to be relatively rare in the general population.
Point prevalence rates of the established and well-known eating disor-
ders, Anorexia Nervosa and Bulimia Nervosa, are estimated to be no
higher than about 2% (Smink, van Hoeken, & Hoek, 2012). Given this
disparity, and what seem to be impossibly high prevalence rates, one
explanation for such high rates is the absence of items on any of the
ON measurement scales that ask about disruption in everyday function-
ing, interpersonal distress, or health problems because of diet. It can be
difficult to determine when a particular behavior can be described as
extreme, or atypical, but not yet pathological.
One widely accepted practice to determine pathological behavior, or
“clinical significance,” is whether the behavior is interpersonally
distressing, or causes impairment in important areas of functioning:
occupational, social, or educational (Spitzer & Wakefield, 1999). Behav-
ior also crosses a line from extreme to an area of concern when individ-
uals suffer medical effects from their actions. Taken in this light, without
items that identify clinically significant behavior, interpersonal distress,
or medical problems concerning diet, it is possible that these scales are
simply identifying healthy eating. Their flaw, then, is that they do not si-
multaneously determine whether the behavior is also pathological. This
certainly can account for why there are high numbers of individuals
scoring in the ON range in particular groups, such as 86% of Ashtanga
yoga practitioners (Valera et al., 2014), 88.7% of nutrition students
(de Souza & Rodrigues, 2014), and 81.9% of dietitians (Alvarenga et al.,
2012).
Other authors also raise concerns about these instruments.
Ramacciotti et al. (2011), for example, worry that the cutoff score of
40 on the ORTO-15 is too high, resulting in too many false positives,
suggesting that a score of 35 would improve detection. They note that
the prevalence rate in their sample drops from 57.6% to 11.9% by making
such an adjustment. Others have concerns about the psychometric
properties of the ORTO-15 (Missbach et al., 2015; Varga et al., 2014).
Donini et al. (2005) are commended for this early, important first step
in attempting to validate an ON measure, however, the ORTO-15 has
several psychometric limitations. There is inadequate evidence that
the authors followed a traditional approach of test construction. Devel-
opment of construct validity is not clearly articulated, the creation of an
item pool is not discussed, standardization methods are absent, and no
basic psychometric properties are provided; all are essential features
of test construction (Cicchetti, 1994; Clark & Watson, 1995; Cook &
Summary
The ORTO-15 was translated into Turkish using a complex, multistep method
and administered to 994 members of a university. The authors found through
confirmatory factor analysis that only 11 of the 15 items from the ORTO-15 were
needed to identify ON.
These authors translated the ORTO-15 into Hungarian using a complicated,
multistep procedure. The translated ORTO-15 was administered to 810
university students. Confirmatory factor analysis also revealed that a shortened
instrument was adequate to identify ON.
Brytek-Matera et al. refer to the “ORTHO-15” when they clearly mean the
ORTO-15. They translate the ORTO-15 from English to Polish using a
complicated, multistep method. The resulting items were administered to 400
members of a university community. Through exploratory and confirmatory
factor analyses, only nine items were “distinguished as valid” for use in a Polish
population.
Using a complicated multistep method the ORTO-15 was translated into German
and administered to 1029 individuals free from medical conditions that could
influence diet (such as celiac or Crohn's disease). Following confirmatory factor
analysis, the model with the best fit was a nine item instrument.
Beckman, 2006; Cronbach & Meehl, 1955). Further, adapting a measure
developed in one culture to be used in another is difficult. When Bosi
et al. (2007) took the ORTO-15 from Italian researchers, they acknowl-
edge they were using a North American construct of healthy eating
(the Bratman Test), that had been translated into Italian (and
expanded from a yes/no format to a scale), with items reported in an
English language journal, that they then translated into Turkish. Many
adaptations of the ORTO-15 do not go beyond simple translation of
test items. It is mandatory that attention be paid to whether features
of one culture are adequately captured by the instrument when used
in another country (Geisinger, 1994).
3. Analysis
The ON literature tends to be published by European researchers
with a small number of articles based in South American or Australian
journals. Data-driven studies are dominated by articles determining
prevalence in a particular sample using the ORTO-15 or one of its adap-
tations. As mentioned above, there are many shortcomings regarding
ORTO-15. We echo the concerns of Varga, Dukay-Szabó, Túry, and van
Furth (2013) and Missbach et al. (2015) and urge caution using the
ORTO-15, or its derivatives, to reliably measure prevalence of ON due
to psychometric limitations. There are also cultural concerns regarding
U.S. criteria being translated for use in other countries. Finally, it is likely
that the instruments used to sample prevalence are not taking into
account whether eating behavior is becoming clinically significant or
inducing medical problems. This also can account for why prevalence
rates are much higher than other eating disorders. In short, there are
no reliable studies regarding the prevalence of ON.
While the literature is limited in this area, there are convincing case
studies and broad anecdotal evidence to conclude that sufficient
evidence exists to pursue whether ON is a distinct condition. At present,
using the DSM classification system, disordered eating driven by the
need to follow an obsessively rigid diet designed to promote good
health would likely be best classified as “Avoidant/Restrictive Food
Intake Disorder,” (ARFID) (Kreipe & Palomaki, 2012). This disorder
manifests by disinterest in eating, avoiding food of certain colors or
shapes, or concern about the aversive consequences of eating. As
the concern about the aversive consequences of eating is typically
interpreted as a response to a previous traumatic event (such as chok-
ing) or aversive experience (like repeated vomiting) (Bryant-Waugh &
Kreipe, 2012; Kreipe & Palomaki, 2012), and not due to concerns
about being unhealthy, we believe that ON is not adequately described

Table 3
A summary of studies reporting prevalance of orthorexia nervosa (ON) using the ORTO-15, or a derivative, in chronological order.
Study
Donini et al. (2005)
Bosi et al. (2007)
Aksoydan and Camci (2009)
Fidan, Ertekin, Işikay,
and Kirpinar (2010)
Ramacciotti et al. (2011)
Alvarenga et al. (2012)
Segura-García et al. (2012)
de Souza and Rodrigues (2014)
Varga et al. (2014)
Valera, Ruiz, Valdespino,
and Visioli (2014)
Asil and Sürücüoğlu (2015)
Brytek-Matera, Donini, Krupa,
Poggiogalle, and Hay (2015)
Gubiec et al. (2015)
Jerez et al. (2015)
Missbach et al. (2015)
Stochel et al. (2015)
Segura-Garcia et al. (2015)
by ARFID. Certainly, an argument could be made for simply describing
ON as a subtype of ARFID. However, given that our understanding of
pathologically healthful eating is evolving, we propose that further
study of the condition, with its own diagnostic criteria as if it were a
condition separate from ARFID, is appropriate.
T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17 15
Prevalence rate (%) Country Summary
6.9 Italy This article describes the creation of the ORTO-15, a 15 item instrument to detect ON
based on Bratman's 10 yes/no items. The ORTO-15 is based on a 525 person sample from
the community. By identifying individuals who were classified as having both “health
fanatic eating habits” and obsessive/compulsive traits and phobia “linked to personality”
based on Scale 7 of the original version of the Minnesota Multiphasic Personality
Inventory, an orthorexia group (n = 121) was identified. A cutoff score of 40 correctly
classified 100% of those in the orthorexia group.
45.5 Turkey The ORTO-15 is translated into Turkish using a single step design. When administered to
318 resident physicians, nearly half score in the range of ON.
56.4 Turkey Using the Bosi et al. (2007) ORTO-15 translation, 94 Turkish artists were evaluated.
Overall, more than half scored in the ON range. Of the different types of artists, 81.8% of
opera singers, 32.1% of ballet dancers, and 36.4% of musicians were identified by the
ORTO-15 as having ON.
43.6 Turkey This study used the “ORTO-11,” an instrument developed from the ORTO-15 by Arusoğlu
et al. (2008). When sampling 878 Turkish medical students, more than 40% were believed
to suffer from ON.
57.6 Italy The aim of this study was to determine ON in the “general population.” When using the
Donini et al. (2005) cutoff score of 40, the prevalence rate was 57.6%. The authors suggest
a different cutoff ORTO-15, a score of 35 (derived arbitrarily for a “sensibly lower”
prevalence rate), that results in only 11.9% of their sample scoring in the ON range.
81.9 Brazil The ORTO-15 was translated into Portuguese using a multistep method, using both the
published English items and its original items in Italian. In a sample of 392 Brazilian
dietitians, more than 8 out of 10 score in the ON range. This group also reports severe
reservations regarding the ORTO-15 based on its psychometric properties.
Men: 28 Italy An examination of 577 Italian athletes, where 28% of women and 30% of men scored in
Women: 30 the ON range on the ORTO-15 using a cutoff score of 35.
88.7 Brazil A second study involving the ORTO-15 in Portuguese. These authors used an instrument
that was the result of a complicated, multistep “cultural adaptation” of the ORTO-15 by
Pontes et al. (2014). Nutrition students (n = 150), all women, were sampled and nearly 9
out of 10 showed “high risk behavior” for ON.
74.2 Hungry The authors used a complicated multistep method to adapt the English items of the
ORTO-15 into Hungarian. They administered this instrument to 810 college students,
funding about three out of four scored in the ON range when using the cutoff score of 40.
They further performed factor analysis and identified only 9 items were indicated. They
call their new instrument the ORTO-11-Hu.
86 Spain When 136 members of a Spanish Ashtanga yoga community were sampled, almost 90%
scored in clinical range for ON with the ORTO-15 cutoff score of 40 and 43% when a cut
score of 35 was used. The authors do not describe their process of adapting the English
items into Spanish, but infer that their participants were directed to an online version of
the original (English) items.
41.9 Turkey Despite referencing the ORTO-11, the authors administer the ORTO-15 to 117 Turkish
dieticians. There is no description of their method to translate the instrument from
English into Turkish. Using a cutoff score of 40, they find a prevalence rate of higher than
40%.
Men: 43.2 Poland Brytek-Matera et al. (2014) created the “ORTHO-15,” a Polish version of the ORTO-15.
Women: 68.6 Using it, this group administered it to 327 college students, identifying a majority of
women and nearly half of men were “preoccupied with consuming healthy food.” Their
cutoff score was 40.
59 Poland The sample consisted of 155 Polish nutrition students. The ORTO-15 was simply
translated from English to Polish by one of the authors. Almost 60% of their sample was
believed to have ON, using a 40 as the cutoff score.
30.7 Chile High school students (n = 205) made up this sample. The authors do not describe their
process for translating the ORTO-15 into Spanish. Using a cutoff score of 35, they report 3
out of 10 students having “orthorexic behavior.”
69.1 Austria After a complicated, multistep translation method, this group derived a German language
version of the ORTO-15. They administered the translated instrument to 1029 people
recruited through social media. Confirmatory factor analysis showed that only nine items
were necessary. Even then, however, Missbatch et al. still found almost 70% of their
sample showed “orthorectic” tendencies.
Study 1: 53.7 Poland This is another translation of the ORTO-15 (Italian items) into Polish using a complex,
Study 2: 52.6 multistep method. Once translated, the Polish version was administered to 399 Polish
high school students. This was a reliability study, with the translated ORTO-15
administered twice under similar conditions. In both studies, more than half the sample
scored in the ON range when a cutoff score of 40 was used.
Clinical: 58 Italy This study is unique in that it compares an eating disorder sample (n = 32) to a matched
Control: 6 sample, healthy control participants (n = 32). It has a very small sample size to be
convincing as a prevalence study, but indicates that ON may become prevalent during the
recovery phase of either anorexia nervosa or bulimia nervosa.
4. Proposed diagnostic criteria
At present, only the Moroze et al. (2015) criteria for ON are widely
available. While these criteria do acknowledge an obsessive–compul-
sive feature thought to be present in the condition as cogently reviewed
16 T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
by Koven and Abry (2015) and demonstrated by Koven and
Senbonmatsu (2013), the Moroze et al. (2015) criteria do not address
the role of weight loss in ON. Additionally, the criteria erred by including
details of one specific dietary theory rather than recognizing that the
content of the dietary theories embraced by individuals with ON may
be fluid. In order to improve the conceptualization of ON, new diagnos-
tic criteria are presented below. It is believed that with developed
criteria, better measures will follow. Better measures will bring more
valid prevalence rates, identify risk factors, and help validate treatment
modalities. These criteria were generated after a critical review of
published case histories, narrative descriptions presented by eating
disorders professionals, and several hundred self-reports of ON sent to
a website maintained by one of the authors (SB). Additionally, develop-
ing versions of the criteria were discussed with and commented upon
by eating disorders professionals from the U.S., Norway, Poland,
Sweden, Australia, Italy, and Germany. Conceptually there was broad
agreement on the definition as presented below.
The opening paragraph for Criterion A is intended as a condensed
narrative description of the condition. Criterion A1 is designed to
capture the fundamental characteristic of orthorexia: excessive focus
on a theory of healthy eating. A2 describes the exaggerated emotional
and physical responses to dietary transgression that separate ordinary
health-food enthusiasm from a potential illness. A3 indicates the typical
pattern of escalation that transforms mildly disordered eating into
significant pathology. Criterion B is included to indicate the wide
range of possible impairments associated with the condition, from the
relatively subtle to the life-threatening. In consideration of the above,
we propose the following:
4.1. Proposed diagnostic criteria for ON
4.1.1. Criterion A
Obsessive focus on “healthy” eating, as defined by a dietary theory or
set of beliefs whose specific details may vary; marked by exaggerated
emotional distress in relationship to food choices perceived as
unhealthy; weight loss may ensue as a result of dietary choices, but
this is not the primary goal. As evidenced by the following:
1. Compulsive behavior and/or mental preoccupation regarding
affirmative and restrictive dietary practices2 believed by the individ-
ual to promote optimum health.3
2. Violation of self-imposed dietary rules causes exaggerated fear of
disease, sense of personal impurity and/or negative physical sensa-
tions, accompanied by anxiety and shame.
3. Dietary restrictions escalate over time, and may come to include
elimination of entire food groups and involve progressively more
frequent and/or severe “cleanses” (partial fasts) regarded as purify-
ing or detoxifying. This escalation commonly leads to weight loss,
but the desire to lose weight is absent, hidden or subordinated to
ideation about healthy eating.
4.1.2. Criterion B
The compulsive behavior and mental preoccupation becomes
clinically impairing by any of the following:
1. Malnutrition, severe weight loss or other medical complications from
restricted diet.
2. Intrapersonal distress or impairment of social, academic or vocation-
al functioning secondary to beliefs or behaviors about healthy diet.
3. Positive body image, self-worth, identity and/or satisfaction
excessively dependent on compliance with self-defined “healthy”
eating behavior.
2
Dietary practices may include use of concentrated “food supplements.”
3
Exercise performance and/or fit body image may be regarded as an aspect or indicator
of health.
Other traits in the literature are commonly associated with ON.
While the authors feel that these are not essential to making the
diagnosis, they may help confirm it. These include obsessive focus on
food choice, planning, purchase, preparation, and consumption; food
regarded primarily as source of health rather than pleasure; distress or
disgust when in proximity to prohibited foods; exaggerated faith that
inclusion or elimination of particular kinds of food can prevent or cure
disease or affect daily well-being; periodic shifts in dietary beliefs
while other processes persist unchanged; moral judgment of others
based on dietary choices; body image distortion around sense of physi-
cal “impurity” rather than weight; and persistent belief that dietary
practices are health-promoting despite evidence of malnutrition.
5. Limitations
This analysis is limited to studies that are in the peer-reviewed
literature, books, and book chapters. It is possible that there are impor-
tant studies that are theses and dissertations and have not yet been
published. Additionally, some caution should be exercised when using
“machine translation” to translate articles into English. However, there
is evidence that suggests data extraction using Google Translate is
acceptable (Balk et al., 2013). Further, there were only three non-
English studies, not likely sufficient to influence the analysis. The
proposed diagnostic criteria also have limitations, chief among them is
that they are not empirically derived. However, defining criteria about
a condition is an essential first step to being able to measure it (Kline,
1986). It is also similar to the process used when establishing Binge
Eating Disorder as a distinct disorder (Spitzer et al., 1992; Yanovski,
1993). It is our hope that other researchers will build upon these criteria
and further refine them. Finally, given that ON is presently generating
more interest in academic circles outside of North America, the criteria
should be applicable to a wide number of cultures. This may be prob-
lematic as the criteria were developed by U.S. researchers. However,
the criteria were refined with the input from eating disorder specialists
outside the U.S. Still, they may have limited utility in African or Asian
populations. Translating the criteria into other languages using a multi-
step process, with attention paid to whether there is fidelity between
the English meaning and resulting items, will maximize utility in
other cultures.
6. Conclusion
Despite flawed measurement tools to assess ON, there is sufficient
evidence that ON is a distinct condition that is different from ARFID.
Unlike ARFID, individuals with ON choose not to restrict their intake
based a disinterest in food, the sensory properties of what they eat, or
because of a previous aversive experience with food, but because of a
pathological drive to be as healthy as possible. While these individuals
can suffer severe medical consequences due to their behavior, like
many with anorexia nervosa, those with ON tend not to have issues
with how their perceive their weight or body shape, nor is their self-
evaluation unduly influenced by weight or shape. These distinctions
are important, as traditional treatment approaches to eating disorders
like anorexia may not be appropriate for those with ON. Finally, there
is a paucity of research in this area. The existing research is largely
based on non-clinical samples and a small number of case studies.
Future directions for scholarship with ON will need to focus on clinical
samples and development of psychometric instruments to aid in diag-
nosis and measuring treatment efficacy.
Acknowledgement
The authors are indebted to Emily Richter Ph.D.; Sibel Golden Ph.D, LMHC; Karin
Kratina PhD, RD, LDN, SEP and Rebecca Reynolds, MSc, PhD, RNutr for their thoughtful
comments regarding diagnostic criteria.
 T.M. Dunn, S. Bratman / Eating Behaviors 21 (2016) 11–17
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